Basic Information
| Provider Information | |||||||||
| NPI: | 1487042974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKMAN | ||||||||
| FirstName: | KATHRYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4851 INDEPENDENCE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034250030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3595 S TELLER ST | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802352014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034250030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2015 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC.0014096 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.